Summary. Analysis of existing data of patients who had undergone debridement procedure for osteoarthritis (OA) of glenohumeral joint showed improvement in disability at a minimum of one year following surgery. Injured workers were significantly younger and had a poorer outcome. Introduction. There is little information on debridement for OA of the shoulder joint. The purpose of this study was to examine factors that affect the outcome of arthroscopic debridement with or without acromioplasty /resection of clavicle of patients with osteoarthritis of the glenohumeral joint, in subjective perception of disability and functional range of motion and strength at a minimum of one year following surgery. Patients and Methods. Existing data of patients with advanced OA of the glenohumeral joint who had undergone debridement were used for analysis. These patients were not good candidates for shoulder arthroplasty due to a young age, high activity level, or desire to avoid major surgery at the time of assessment. Arthroscopic debridement included removal of loose bodies, chondral flaps, and degenerative tissue. Resection of the lateral end of the clavicle or acromioplasty was performed as clinically indicated for management of osteoarthritis of the Acromioclavicular (AC) joint or subacromial impingement respectively. Disability at a minimum of 12 months following surgery was measured by the American Shoulder and Elbow Surgeon's (ASES) assessment form, Constant-Murley score (CMS), strength, and painfree range of motion (ROM) in four directions. Impact of sex, age, having acromioplasty or resection of clavicle, and having an active work-related compensation claim was examined. Results. Seventy-four patients (mean age= 55, SD: 14 (range: 25–88), range: 35–86, 34 females, 40 males) were included in analysis. The average symptom duration was 5.8 years. Fifty nine (80%) patients had an associated subacromial decompression [55 (74%) had acromioplasty, 32(43%) had resection of the lateral end of the clavicle, and 28 (38%) had both procedures]. Nineteen (26%) patients had a work-related compensation claim related to their shoulder. This group was significantly younger than the non-compensation group (45 vs. 58, p=0.0001). Paired student t-tests showed a statistically significant improvement in scores of ASES and CMS (p<0.0001), strength (p=0.001) and painfree range of motion (p=0.01) at a minimum of 1 year follow-up. The ANCOVA model that incorporated sex, age, additional decompression (AC resection or acromioplasty), compensation claim and pre-op scores, showed that the pre-op scores and having a work-related claim were the most influential predictors of post-op scores of ASES, CMS, and ROM. The post-op strength was the only factor that was affected by sex, age and having a work-related claim. Discussion/Conclusion. Arthroscopic debridement with or without acromioplasty /resection of the lateral end of the clavicle improved disability, painfree range of motion and strength in patients suffering from osteoarthritis of glenohumeral joint at a minimum of one year following surgery. Patients with an active compensation claim related to their shoulder were significantly younger and had a poorer outcome

Despite widespread use, the benefit of knee arthroscopy for symptomatic osteoarthritis (OA) remains controversial. The theoretical benefit of removal of particulate debris and washout of inflammatory cytokines has not been supported by strong evidence. Arguments exist for its short term benefit in well selected patients. We sought to determine if arthroscopy provided any short term symptomatic relief in patients with a clinical diagnosis of OA in our unit. A total of 20 patients were listed for routine arthroscopy over a one year period for OA. Mean age was 60 (range 48–74) years and 3 in 5 patients were female. 9 patients were listed by registrars, 6 by locum consultants and 5 by substantive consultants. One procedure was cancelled on the day of surgery due to lack of indication, with 19 knees proceeding to surgery. There was evidence of significant arthritis in 17 knees, 6 of which had associated degenerate meniscus tears. Two knees had meniscus tears without significant arthritis. All patients had washout and debridement and in addition, 8 partial menisectomies were carried out together with 3 loose body removals. Patients were followed up after an average of 12 weeks. The 2 patients (both male, mean age 52) with meniscus tears in the absence of significant arthritis fully recovered. Both had symptoms of true locking. 2 patients with loose bodies also fully recovered. With the exception of 2 patients with partial relief, the remainder had no symptomatic relief. One reported a worsening of symptoms and progressed to total knee arthroplasty. These results suggest that arthroscopic debridement and washout plays a limited role in the short term symptomatic relief of OA. Surgeons should limit its use to younger patients with mild radiographic disease and true mechanical symptoms who are otherwise unsuitable for arthroplasty and not keen on undergoing joint conserving surgery

Adequate range of knee motion is critical for successful total knee arthroplasty. While aggressive physical therapy is an important component, manipulation may be a necessary supplement. There seems to be a lack of consensus with variable practices existing in managing stiff postoperative knees following arthroplasty. Hence we did a postal questionnaire survey to determine the current practice and trend among knee surgeons throughout the United Kingdom. A postal questionnaire was sent out to 100 knee surgeons registered with British Association of Knee Surgeons ensuring that the whole of United Kingdom was well represented. The questions among others included whether the surgeon used Manipulation Under Anaesthaesia (MUA) as an option for stiff postoperative knees; timing of MUA; use of Continuous Passive Motion (CPM) post-manipulation. We received 82 responses. 46.3% of the respondents performed MUA routinely, 42.6% sometimes, and 10.9% never. Majority (71.2%) performed MUA within 3 months of the index procedure. 67.5% routinely used CPM post-manipulation while 7.3% of the respondents applied splints or serial cast post MUA. 41.5% of the surgeons routinely used Patient Controlled Analgaesia +/− Regional blocks. Majority (54.8%) never performed open/arthroscopic debridement of fibrous tissue for adhesiolysis. Knee manipulation requires an additional anaesthetic and may result in complications such as: supracondylar femur fractures, wound dehiscence, patellar tendon avulsions, haemarthrosis, and heterotopic ossification. Moreover studies have shown that manipulation while being an important therapeutic adjunct does not increase the ultimate flexion that can be achieved which is determined by more dominant factors such as preoperative flexion and diagnosis. Manipulation should be reserved for the patient who has difficult and painful flexion in the early postoperative period

Introduction. Ostochondral lesion of the knee is a common cause of chronic knee pain. Arthroscopic treatment with subcondral microfracture is a widespread technique leading to noticeable improvement of knee function and pain. To improve the effectiveness of this treatment options, we thought to add intra (PRF) or post-operative (PRP) growth factors. Platelet rich plasma (PRP) is obtained by centrifugation of the blood to produce a plasma with high concentration of platelets and growth factors. This latter represents a promising method to manage degenerative cartilage lesion and can be used postoperatively to improve clinical results of patients treated arthroscopically. Platelet Rich Fibrin (PRF) has been presented as a second-generation platelet concentrate, and it is used intraoperatively to cover the microfracuteres’ holes. No literature was found about using of PRF intraoperative in association with arthroscopic microfracture technique. The aim of this study is to compare clinical outcomes of the treatment of knee osteochondral lesion using arthroscopic microfracture technique alone or in association with PRF Intraoperative application using “Vivostat” system or with PRP “ReGen Lab” postoperative injection. Patients & Methods. 90 patients with clinical and radiographic evidence of osteochondral lesion of the medial or lateral compartment of the knee were enrolled. All patients received arthroscopic debridement and Microfractures and were randomised into 3 groups: 30 patients received microfractures and intraoperative PRF “Vivostat” injection(Group A), 30 patients received microfracture and 3 intra-articular injections of 5.5 mL PRP “Regen”(Group B), 30 patients received microfracture only. IKDC, KOOS and VAS score were administered to all patients before starting the treatment, at 1, 6 and 12 months from the end of the management. Results. Patients who received microfracture and PRF intraoperative application provided the best outcomes, showing a significant higher clinical scores (P<0.001) compared to the other two groups. Patients underwent PRP postoperative administration reported significant higher score than those undergoing arthroscopic microfracture alone (P<0.005), but lesser than Intraoperative PRF group at 6 months and 1 year follow up. Discussion/Conclusion. Treatment of osteochondral lesions of the knee using microfracture technique significantly improved functional and pain scores from the pre- to postoperatively time in the overall cohort. Intraoperative application of PRF shows significantly better outcome than postoperative PRP injections. However, additional treatment with intra-articular PRP injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone

Summary. The dGEMRIC index correlates more strongly with the pattern of radiographic joint space narrowing in hip osteoarthritis at five year follow-up than morphological measurements of the proximal femur. It therefore offers potential to refine predictive models of hip osteoarthritis progression. Introduction. Longitudinal general population studies have shown that femoroacetabular impingement increases the risk of developing hip osteoarthritis, however, morphological parameters have a low positive predictive value. Arthroscopic debridement of impingement lesions has been proposed as a potential strategy for the prevention of osteoarthritis, however, the development of such strategies requires the identification of individuals at high risk of disease progression. We investigated whether delayed Gadolinium-Enhanced MRI of Cartilage (dGEMRIC) predicts disease progression. This imaging modality is an indirect measure of cartilage glycosaminoglycan content. Patients and Methods. 34 asymptomatic individuals from a longitudinal cohort study (sibkids) were assessed at baseline with the collection of Patient Reported Outcome Measures (PROMs), anteroposterior and cross-table lateral radiographs, 3D morphological MRI, and dGEMRIC at 3T of their index hip. A dGEMRIC index was calculated as a ratio of the anterosuperior acetabular cartilage T1 relaxation time and the total femoral and acetabular cartilage T1 relaxation time. 29 individuals were followed up at 5 years for repeat assessment (average age 51 years and range 36 to 67). Radiological measurements were made by a single observer using in house Hipmorf software. Radiographic disease progression was assessed using minimum joint space width (JSW), lateral sourcil JSW, and medial sourcil JSW. These were measured on baseline and five year follow-up anteroposterior radiographs with an intra-observer ICC of 0.916. Alpha angle measurements were made by the same observer on radiographs and MRI radial slices with an intra-observer ICC of 0.926. Results. Mean minimum JSW for the cohort fell by 0.16mm over five years (p=0.024). Baseline dGEMRIC index did not correlate with change in minimum JSW (r=0.031 p=0.873). There was a moderate correlation between baseline dGEMRIC and the direction of JSW loss (change in JSW at the lateral sourcil minus change in JSW at the medial sourcil) (r=0.561 p=0.002). There was a weak correlation between the change in Non-Arthritic Hip Score and baseline dGEMRIC (r=0.256 P=0.180). Maximum alpha angle measured on baseline MRI radial slices did not correlate with change in minimum JSW and weakly correlated with the direction of JSW narrowing (r=0.273 p=0.160). Conclusion. A low dGEMRIC index indicates reduced glycosaminoglycan concentration in the anterosuperior acetabular cartilage compared with the total femoral and acetabular cartilage. This correlates with lateral JSW narrowing relative to medial JSW narrowing as osteoarthritis progresses. The dGEMRIC index correlates better with osteoarthritis progression than alpha angle measurements and offers the potential to refine a predictive model for osteoarthritis progression to aid patient selection for clinical trials

We assessed the predictive value of the macroscopic and detailed microscopic appearance of the coracoacromial ligament, subacromial bursa and rotator-cuff tendon in 20 patients undergoing subacromial decompression for impingement in the absence of full-thickness tears of the rotator cuff. Histologically, all specimens had features of degenerative change and oedema in the extracellular matrix. Inflammatory cells were seen, but there was no evidence of chronic inflammation. However, the outcome was not related to cell counts.

At three months the mean Oxford shoulder score had improved from 29.2 (20 to 40) to 39.4 (28 to 48) (p < 0.0001) and at six months to 45.5 (36 to 48) (p < 0.0001). At six months, although all patients had improved, the seven patients with a hooked acromion had done so to a less extent than those with a flat or curved acromion judged by their mean Oxford shoulder scores of 43.5 and 46.5 respectively (p = 0.046). All five patients with partial-thickness tears were within this group and demonstrated less improvement than the patients with no tear (mean Oxford shoulder scores 43.2 and 46.4, respectively, p = 0.04). These findings imply that in the presence of a partial-thickness tear subacromial decompression may require additional specific treatment to the rotator cuff if the outcome is to be improved further.

Recently, femoroacetabular impingement has been recognised as a cause of early osteoarthritis. There are two mechanisms of impingement: 1) cam impingement caused by a non-spherical head and 2) pincer impingement caused by excessive acetabular cover. We hypothesised that both mechanisms result in different patterns of articular damage. Of 302 analysed hips only 26 had an isolated cam and 16 an isolated pincer impingement. Cam impingement caused damage to the anterosuperior acetabular cartilage with separation between the labrum and cartilage. During flexion, the cartilage was sheared off the bone by the non-spherical femoral head while the labrum remained untouched. In pincer impingement, the cartilage damage was located circumferentially and included only a narrow strip. During movement the labrum is crushed between the acetabular rim and the femoral neck causing degeneration and ossification.

Both cam and pincer impingement lead to osteoarthritis of the hip. Labral damage indicates ongoing impingement and rarely occurs alone.

We compared the quality of debridement of chondral lesions performed by four arthroscopic (SH, shaver; CU, curette; SHCU, shaver and curette; BP, bipolar electrodes) and one open technique (OPEN, scalpel and curette) which are used prior to autologous chondrocyte implantation (ACI). The ex vivo simulation of all five techniques was carried out on six juvenile equine stifle joints. The OPEN, SH and SHCU techniques were tested on knees harvested from six adult human cadavers.

The most vertical walls with the least adjacent damage to cartilage were obtained with the OPEN technique. The CU and SHCU methods gave inferior, but still acceptable results whereas the SH technique alone resulted in a crater-like defect and the BP method undermined the cartilage wall. The subchondral bone was severely violated in all the equine samples which might have been peculiar to this model. The predominant depth of the debridement in the adult human samples was at the level of the calcified cartilage. Some minor penetrations of the subchondral end-plate were induced regardless of the instrumentation used.

Our study suggests that not all routine arthroscopic instruments are suitable for the preparation of a defect for ACI. We have shown that the preferred debridement technique is either open or arthroscopically-assisted manual curettage. The use of juvenile equine stifles was not appropriate for the study of the cartilage-subchondral bone interface.

Repeated trauma to the radial head may be one of the causative factors in the genesis of osteochondritis dissecans of the capitellum. We measured the force, contact area and pressure across the radiocapitellar articulation of the elbow before and after radial shortening osteotomy in five fresh-frozen cadaver upper limbs with loads of 45, 90 and 135 N, respectively. Measurements were made on pressure-sensitive film placed in the radiocapitellar articulation with the forearm in the supinated, neutral and pronated positions before and after radial shortening. Radial shortening significantly reduced the mean force and contact area across the radiocapitellar articulation in all positions of the forearm.